Program Consent Form printable pdf download

Program Consent Form

Local PTA Reflections Program Consent Form

California State PTA

Local Unit___________________ Council___________________________ District #______________

For Use of a Student’s Image or Voice

I give my permission for my son/daughter, _______________________, to participate in the taping,

photographing, or audio recording of an entry in the PTA Reflections

Program. I give consent for

the student’s voice and or image to be included in the entry. This entry may be used in perpetuity in

connection with the PTA Reflections Program or other PTA purposes. I understand that entries may

be judged at the local, regional, state, and national level. Entries may be displayed at a school or at

another public area, including the Internet.

Name of Student Submitting the Entry

I have read and understand the Rules of the Reflections Program.

Student Name

Parent/Guardian Printed Name

Date

Parent/Guardian Signature

Date

For Use of an Adult’s Image or Voice

I am 18 years or older and I consent to participate in the taping, photographing, or audio recording

of an entry in the PTA Reflections® entry. This entry may be used an unlimited number of times in

perpetuity in connection with the PTA Reflections Program or other PTA purposes. I understand

that entries may be judged at the local, regional, state, and national level. Entries may be displayed

at a school or at another public area, including the Internet.

Name of Student Submitting the Entry

I have read and understand the Rules of the Reflections Program.

Printed Name

Date

Signature

Date

Program Consent Form